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PREGNANCY ¹

NERVE

Cranial neuropathies

• Frequency
  • Up to 3.3 times rate in non-pregnant women
  • Some studies show no assocation with pregnancy
• Onset times
  • 3rd trimester & Post-partum
• Associations: Hypertension, Preeclampsia, Obesity
• Prognosis
  • More likely to progress to complete paralysis
  • Recovery, partial or complete, in most

Upper extremity neuropathies

• Epidemiology: Pregnancy
  • Frequency
    • General: 17%: Range 0.34% to 59%
    • Higher with: More lifetime pregnancies; Age > 30
    • Hand symptoms: Up to 60%
  • White-collar occupations: More
• Clinical: Pregnancy
  • Shorter duration of symptoms
  • Bilateral: More frequent
  • Severity: Less clinical & electrophysiologic than other CTS
  • Onset: Most common in 3rd trimester
  • Treatment: Symptomatic
    • Neutral position wrist splints
    • Salt reduction
    • Carpal canal corticosteroid injection
  • Possible surgery indications
    • Intolerable sensory symptoms: No improvement with conservative management
    • Focal motor conduction block across carpal ligament persistent after delivery
      • ? Increased likelihood of 2° axon loss to abductor pollicis brevis
• After delivery
  • Resolution rates
    • 50% over 1 to 2 years without treatment
    • 67% after 3 years
    • Less resolution
      • Onset early in pregnancy
      • More weight gain during pregnancy
  • Post-partum CTS: Some reports with breast feeding
• Asymptomatic CTS
  • Electrodiagnostic: Median sensory latencies (average) longer in pregnant patients

• No general association with pregnancy
• Compressive lesions at spiral groove: Reported during birthing

• No definite involvement

• Clinical
  • Pain: Distribution of a thoracic root or intercostal nerve
  • Course: Symptoms remit rapidly after delivery
  • Recurrence: With subsequent pregnancies
• EMG: Thoracic paraspinous denervation
• Other thoracic root syndrome: Notalgia paresthetica

Lower extremity neuropathies

• Frequency: Up to 9%
• Risk factors
  • Prolonged pushing during 2nd stage of labor
  • High fetal station
  • Semi-Fowler lithotomy positions: Legs flexed at hips, abducted & externally rotated

• Most frequent lower extremity mononeuropathy
• Causes
  • Compression
    • Location: Over inguinal ligament at anterior superior iliac spine
    • Time: Maternal pushing in thigh-flexed posture
  • Transection: Wide Pfannenstiel incision at cesarean section
  • Stretched: Retraction
• Clinical
  • Onset: Before or after delivery; C-section
  • Unilateral or Bilateral
  • Treatment: Pain management

• Rare (0.3%)
• Risk factors
  • Primiparous women
  • Labor prolonged
  • During delivery
• Locations
  • Inguinal ligament
  • Psoas retraction
• Position
  • Thigh flexion, external rotation & abduction
  • Lithotomy

• Root innervation: L3 > L2 & L4
• Derived from: Lumbar plexus
• Muscles: Adductors, thigh; Gracilis; Obturator externus
• Risk factors
  • During delivery: Fetal head; Forceps
• Clinical
  • Pain: Medial thigh or groin
  • Sensory: Medial thigh in some patients
  • Weakness: Thigh adductors
• Causes
  • Pregnancy: Hematomas after pudendal nerve block
  • Other causes
    • Arthroplasty: Total hip or knee
    • Pelvic surgery or trauma
    • Femoral artery procedures
    • Metastatic disease
    • Prolonged high leg tourniquet
    • Diabetes
    • Myositis ossificans
• Prognosis: Symptoms may improve with conservative management

• Infrequent
• Causes
  • External compression: Obstetric stirrups
  • Forceful knee flexion while pushing during vaginal delivery
• May be bilateral

• Onset
  • Compression by fetal head during the second stage of labor
  • Forceps delivery
• Risk factors
  • Fetal macrosomia: Cephalopelvic disproportion
  • Malpresentations
  • Maternal
    • Pelvic features
    • Short stature
• Clinical
  • Foot weakness: Especially L5 innervation
  • Recovery: In 3–5 months

Polyneuropathies

• No definite increased incidence associated with pregnancy
• More patients: 2nd & 3rd trimesters; 1st month post partum

• Possible increased risk of exacerbation: 3rd trimester & 1 month post partum

• Relapse during pregnancy
  • Occasional
  • Weakness: New or Previously affected muscle groups
• One patient with maternal transmission of IgG vs GM1 ganglioside antibody to child

• Increased frequency of
  • Postpartum bleeding
  • Presentation abnormalities
  • Forcep deliveries

• Avoid nerve compression during pregnancy

NEUROMUSCULAR JUNCTION

• Well controlled MG: Little effect of pregnancy
• Pregnancy effects on MG disease activity: Unpredictable; 30% to 50% worsen
• Delivery: Avoid, or reduce dose of, muscle relaxants
• See: Effects on Fetus & Neonate

MUSCULOSKELETAL

• Frequency: 50% of pregnancies
• Preexisting low back pain: May worsen during pregnancy
• Most common etiologies
  • Sacro-iliac disorders
  • Hip pathology
  • Lumbo-sacral spine disorders
• Delivery & Anesthesia with lumbar spine disc disease
  • ? Use Cesarean section

MUSCLE

• First symptoms may occur during pregnancy or postpartum
• Maternal blood loss at delivery: Associated with congenital DM1
  • Fetal club feet
  • Polyhydramnios
• Pregnancy: Increased frequency of
  • Fetal loss
  • Premature delivery
  • Polyhydramnios
• Child: May have more severe disease than mother

• Weakness & Fatigue
  • Increased during pregnancy: Some patients
  • May improve with carnitine replacement

Medications

• General
  • Corticosteroids: Prednisone relatively safe during pregnancy; Continue during pregnancy; Relative contra-indication
  • Azathioprine: Increased risk of adverse birth outcomes; Low risk with breast feeding; Relative contra-indication
  • Cyclosporine A: Teratogenic; Contraindicated during breast feeding; Determine risk:benefit ratio in individual patients
  • Methotrexate: Teratogenic; Do not use in pregnancy
  • Mycophenolate mofetil: Teratogenic, EMFO syndrome; More severity in 1st trimester; Relative contra-indication
  • IVIg: Determine risk:benefit ratio in individual patients
• Timing ²

  	Conception	During Pregnancy	Breast Feeding	Paternal Exposure
  Corticosteroids Oral or IV	Yes	Yes	Yes	Yes
  Azathioprine	Yes	Yes	Yes	Yes
  Methotrexate	Stop x 4 wks	No	No	Yes
  Mycophenolate Mofetil	Stop x 6 wks	No	No	?
  Cyclophosphamide	No	Sev Dis	No	No
  Rituximab	Sev Dis	Sev Dis	Yes	Yes
  IVIg or SQ Ig	Yes	Yes	Yes	Yes

  Yes = May be used; No = Do not use; Sev Dis = Use only if no alternatives in severe maternal disease
  

• Determine risk:benefit ratio in individual patients: Adverse animal studies; No adequate human studies
  • Acetazolamide
  • Dichlorphenamide (Keveyis)
  • Duloxetine (Cymbalta)
  • Fludrocortisone
  • Gabapentin (Neurontin)
  • Mexiletine
  • Midodrine (ProAmatine)
  • Pregabalin (Lyrica)
  • Pyridostigmine (Mestinon)
  • Riluzole (Rilutek)
  • Tramadol
• Relative contra-indication: Evidence of human fetal risk based on studies or marketing experience
  • Immunosuppressive medications: Most
• No data
  • 3',4'-Diaminopyridine
  • Eculizumab
  • Edaravone
  • Nusinersen
  • Rituximab